A newly licensed nurse is caring for a client who requires tracheal suctioning, which is a procedure the nurse has not performed in practice. Which of the following actions should the nurse take?
Ask an experienced nurse to assist with the procedure.
Refuse to take the assignment.
Identify that the task is in the scope of RN practice and perform the suctioning.
Delegate the task to assistive personnel.
The Correct Answer is A
Choice A reason: Asking an experienced nurse to assist ensures the procedure is performed safely while allowing the newly licensed nurse to gain competence. Tracheal suctioning requires sterile technique and skill to avoid complications like hypoxia or trauma. This approach supports patient safety and professional development, aligning with nursing standards.
Choice B reason: Refusing the assignment is inappropriate, as tracheal suctioning is within an RN’s scope of practice. Refusal avoids responsibility without addressing the client’s needs or the nurse’s professional growth. Seeking assistance ensures safe care while building skills, making this choice less effective and unprofessional.
Choice C reason: Performing tracheal suctioning without prior experience risks patient harm, as it requires precise technique to prevent complications like mucosal damage or infection. Without guidance, errors are more likely. Seeking supervision ensures safety and competence, making this choice unsafe and inappropriate for a novice nurse.
Choice D reason: Delegating tracheal suctioning to assistive personnel is inappropriate, as it is a sterile procedure requiring RN-level skills and judgment. Assistive personnel are not trained for invasive procedures like suctioning, which risks complications. This choice violates delegation principles and compromises patient safety, making it incorrect.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Informed consent does not prevent a client from refusing the procedure, as they retain the right to withdraw consent at any time before or during the process. This statement is incorrect, as it misrepresents the client’s autonomy and legal rights under informed consent principles.
Choice B reason: The nurse’s role in witnessing consent is to verify the client’s voluntary agreement, not to explain the procedure in detail. The surgeon or provider is responsible for detailed explanations, making this action outside the nurse’s scope in this context and incorrect.
Choice C reason: Explaining risks and benefits is the surgeon’s responsibility, not the nurse’s when witnessing consent. The nurse ensures the client understands and agrees voluntarily but does not provide the explanation, making this an incorrect description of the nurse’s role in the process.
Choice D reason: The client’s voluntary agreement is a core legal requirement of informed consent, which the nurse verifies as a witness. This ensures the client understands the procedure, risks, and benefits and consents without coercion, aligning with ethical and legal standards, making it correct.
Correct Answer is C
Explanation
Choice A reason: Keeping the drainage bag above waist level promotes urine backflow, increasing infection risk. Bags must be below bladder level to ensure proper urine flow, so this action is incorrect and unsafe, requiring nurse intervention.
Choice B reason: Disconnecting the catheter to empty the bag breaks the closed system, increasing infection risk. The bag should be emptied via the drainage port, so this action is incorrect and requires correction by the nurse.
Choice C reason: Emptying the drainage bag when three-quarters full prevents overfilling, reducing backflow and infection risk. This aligns with proper catheter care protocols, ensuring safety for a fall-risk client, making it the correct technique.
Choice D reason: Using sterile gloves for emptying the drainage bag is unnecessary, as clean gloves suffice for this non-sterile procedure. Sterile gloves are for catheter insertion, so this action is incorrect and inefficient, requiring guidance.
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